When I entered the mental health field ‘antipsychotic’ agents were referred to as “major tranquilizers.” For multiple reasons, the latter term was dropped to be replaced by the concept of a specific antischizophrenic agent: neuroleptics, first and second generation antipsychotics. The latter agents are now widely used in bipolar disorder as well. Logically, should we now refer to these agents as third generation mood stabilizers (lithium, and depakote and the many other anticonvulsants, being the first and second generation mood stabilizers, respectively)? Or dare we even return to the notion that these agents can be anxiolytic? When I have looked at neuroimaging scans of recovered or improved patients with mental illness, including schizophrenia, paranoia, and affective disorders, I see changes which can be most coherently explained through reductions in chronic and severe arousal, i.e., less anxiety/fear/stress. The neuroscience of schizophrenia is largely nonspecific and is highly congruent with the neuroscience of stress/fear/anxiety.

In Stavanger, Norway, in speaking with Yrjö Alanen about the Finnish research projects for schizophrenia, the latter noted that often their patients could be helped with benzodiazepines alone without exposure to neuroleptic agents. Luc Ciompi, in his theory of Affect-Logic, proposed that schizophrenia is more an affective illness than a cognitive one and that the antipsychotic agents work through dampening down arousal. I fully concur with this. Therefore I would dare to say that antipsychotic agents, both first and second generation agents, do not have a specific anti-delusional or anti-hallucinatory effect. In my practice of almost three decades I have rarely observed that these agents completely eliminate positive or negative symptoms of schizophrenia. Perhaps, it is the sample I have been exposed to. My response to that would be that it is a broad sample, encompassing patients seen in city and state psychiatric units (inpatient and outpatient), private psychiatric inpatient and outpatient centers as well as private practice.

Freeman and Garety ( 2004), in their excellent volume Paranoia: The Psychology of Paranoid Delusions, review the question of a dimensional perspective of neurosis/psychosis as well as the role of emotional disorders in psychotic symptom formation and maintenance. They summarized the psychopharmacological research involving anxiolytic agents in the treatment of psychotic symptoms. They presented research evidence for the efficacy of benzodiazepines in the treatment of schizophrenia. Freeman and Garety noted:

“On the basis of double-blind studies, Wolkowitz and Pickar (1991) conclude that benzodiazepines on their own, especially at high doses, have antipsychotic efficacy for one third to one half of individuals...In an interesting novel use, Kirkpatrick, Buchanan, Waltrip, Jauch, and Carpenter (1989) provide preliminary evidence that diazepam [valium] may be used in the treatment of relapse in schizophrenia” (p.35).

Wolkowitz (1996), in The New Pharmacotherapy of Schizophrenia edited by Alan Breier for American Psychiatric Publishing, Inc., concluded that 30-50% of patients with schizophrenia evidence beneficial effects with benzodiazepine (Bz) use. Nine double-blind research studies of 14, demonstrated efficacy in Bz use. Wolkowitz concluded: “Therefore, benzodiazepines, even when used alone, may have mild antipsychotic efficacy in some patients” (p.158).

Epidemiological, sociocultural and outcome research; phenomenological reports given by patients; neuroimaging and neuroscience research; as well as clinical experience, all point towards the critical role of anxiety and fear in the initiation, course and outcome of the psychotic disorders, including the human illnesses we have called “schizophrenia.”

Brian Koehler PhD
Postdoctoral Faculty
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net